Tallaght has had frequent changes in senior management, with six CEOs in its 13-year history.
A factor in Tallaght's recent problems was the absence through sick leave of one CEO, Michael Lyons, which resulted in others being appointed to 'acting' CEO.
Mr Lyons' permanent replacement, Kevin Conlon, resigned last year.
The hospital has just appointed a new permanent CEO, Eilish Hardiman, who formerly headed up the new Mater children's hospital project.
The fluctuation at the top obviously hasn't helped when it comes to directing hospital policy in a consistent manner.
However, as the 2010 X-ray scandal report pointed out, this chopping and changing is insufficient to explain "the consistent failure of management to take effective action" to deal with problems as they arose.